Citation Nr: 1316626 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 06-28 058A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for malaria. 2. Entitlement to service connection for residuals of a stroke to include as secondary to post-traumatic stress disorder. 3. Entitlement to specially adapted housing. 4. Entitlement to an initial compensable rating for hepatitis C. 5. Entitlement to an initial compensable rating for bilateral foot onychomycosis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to December 1968. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois. Although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable; therefore, the question of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The issue of entitlement to service connection for residuals of a stroke, to include as secondary to post-traumatic stress disorder, is remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. A current diagnosis of malaria, or any residual disability attributable to malaria, is not of record. 2. Service connection is in effect for post-traumatic stress disorder, rated as 100 percent disabling; a right ankle disorder, rated as 10 percent disabling; peripheral neuropathy of the right foot and of the left foot, each separately rated as 10 percent disabling ; hepatitis C, rated as noncompensable; and onychomycosis and tenia pedia of the feet, rated as noncompensable. 3. The Veteran's service-connected disabilities do not result in permanent and total disability compensation due to the loss, or loss of use, of both lower extremities; blindness in both eyes plus the anatomical loss, or loss of use, of one lower extremity; loss, or loss of use, of one lower extremity together with residuals of organic disease or injury which affect functions of balance and/or propulsion so as to prevent locomotion without assistive device; loss, or loss of use, of one lower extremity together with the loss, or loss of use, of one upper extremity such as to affect function of balance or propulsion so as to preclude locomotion without assistive devices; loss, or loss of use, of both upper extremities such as to preclude use of the arms at or above the elbow; or, full thickness or subdermal burns which are related to service or to a service-connected disability. 4. The Veteran's hepatitis C is not symptomatic. 5. The Veteran's bilateral foot onychomycosis affects less than five percent of the total body area, and does not require intermittent systemic therapy. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for malaria have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for entitlement to a certificate of eligibility for specially adapted housing have not been met. 38 U.S.C.A. §§ 2101(a), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.809 (2012). 3. The criteria for an initial compensable disability rating for hepatitis C have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.114, Diagnostic Code 7354 (2012). 4. The criteria for an initial compensable rating for service-connected bilateral foot onychomycosis have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.118, Diagnostic Code 7806 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The RO's September 2004 letter advised the Veteran of the foregoing elements of the notice requirements on the issue of service connection for malaria. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The September 2004 letter did not notify the Veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection was awarded. Dingess/Hartman, 19 Vet. App. at 486. However, the Veteran was notified of such information by a subsequent notice letter sent to him by the RO in March 2006. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, as well as identified private and VA medical treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA provided the Veteran with a VA examination to determine the etiology of his claimed malaria. This medical examination was adequate, as it was based upon a complete review of the evidence of record, consideration of the Veteran's lay statements, and clinical examination of the Veteran. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this regard, the Board also finds that there has been substantial compliance with its prior remand on this issue as the RO provided the Veteran with an adequate VA examination. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. With respect to the increased initial evaluation issues, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. As noted, proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran's claims of entitlement to increased evaluations for his skin disorder and for hepatitis C arise from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed. As to the duty to assist, the Veteran's service treatment records, as well as identified private and VA medical treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA provided the Veteran with VA examinations to evaluate his disorders. The medical examinations were adequate, as they were based upon a complete review of the evidence of record, consideration of the Veteran's lay statements, and clinical examination of the Veteran. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this regard, the Board also finds that there has been substantial compliance with its prior remand on this issue as the RO provided the Veteran with an adequate VA examination. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran himself has not contended nor is there any record in the file to show that there has been a material change in the disabilities. As there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disabilities since he was last examined, reexamination is not warranted, and the Board is deciding the appeal on the current record. The Veteran reported having treatment for malaria and for hepatitis C at Cameron Bay Hospital and NHA Trange Hospital. The RO was unable to locate the records and issued a Formal Finding of Unavailability in January 2013. The Veteran was so informed in a January 2013 letter, and he provided no response. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional available records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. There is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination) (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Moreover, in the case of malaria, service connection as a result of tropical service is granted if such diseases are manifested in service, or manifested following separation from service . 38 U.S.C.A. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To establish direct service connection, there generally must be (1) medical or satisfactory lay evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical or satisfactory lay evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Barr v. Nicholson, 21 Vet. App. 303 (2007). Malaria The Veteran claims that he currently has malaria, as well as headaches as a residual of malaria related to his treatment in service for malaria. The Veteran's service treatment records demonstrate that he was hospitalized for 40 days in November 1966 to treat malaria. Thereafter the service records are silent for a diagnosis, complaint or treatment of the disorder. At service separation in December 1968, no pertinent complaints or findings were noted. When the Veteran was examined by VA in January 2009, the Veteran reported a history of treatment for malaria in service. He stated that he had been asymptomatic. He noted that in 1991 he was hospitalized for a high fever of undetermined etiology and that he was not told at that time that he had malaria. The Veteran reported that in 1997, he was treated for a temperature but also was not told it was due to malaria. He stated that since that time, he had not had recurrent high fevers, chills, shakes, weight loss, or other somatic complaints. He reported his weight was stable, and that he did not have night sweats. On examination, the Veteran was well-nourished and in no acute distress. A malarial smear demonstrated no malarial forms present and the examiner found that there was no active malaria at the present time, and no residuals. The Board has reviewed the evidence in the file including VA and private treatment records; however, none diagnose malaria or any residuals attributable to the disorder. While the Veteran was treated at a private facility in December 1996 for headaches, nausea, and dizziness, after diagnostic testing, the finding was headache, secondary to intarventricular hemorrhage, etiology to be determined. A current disability exists when there is a disability when a claim for it is filed or at any time during the pendency of such claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). A current disability of malaria or any residual thereof is not established. The recent post-service evidence fails to document any episodes of malaria. Moreover, no residuals of malaria have been shown. The Veteran offered testimony at a hearing before the Board in April 2011. He testified that he currently had headaches, for which he takes medication. Acknowledgement is given to the fact that the Veteran has reported symptoms which he asserts are malaria episodes. The Veteran's statements are competent evidence as to episodes of headaches, dizziness, and nausea as they are experienced by him. Layno v. Brown, 6. Vet. App. 465 (1994) (concluding that lay witnesses are competent to provide testimony or statements relating to facts of events that the lay witness observed or that is within the realm of his/her personal knowledge). The Veteran was treated in service for malaria. However, in this case, the Veteran's statements are not competent evidence to diagnose malaria or to conclude that any current symptoms are due to malaria. Id. at 465. Laypersons statements are competent evidence to diagnose a disability only if (1) the disorder is simple to identify, such as a broken leg, (2) the statements report a contemporaneous medical diagnosis, or (3) the description of symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Malaria inherently is not simple to identify since it is diagnosed based on blood tests. Accordingly, the Veteran statements are not competent evidence of a diagnosis of malaria. Moreover, the Veteran's statements are not later supported by a diagnosis from a health care practitioner. In sum, the preponderance of the evidence does not show a current disability of malaria or residual of malaria. As such, the benefit of the doubt rule is inapplicable to this issue. There can be no valid claim absent a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, service connection for malaria is not warranted. Specially Adaptive Housing A certificate of eligibility for assistance in acquiring specially adapted housing may be provided if, among other things, a Veteran is entitled to service-connected compensation for permanent and total disability due to: (1) the loss, or loss of use, of both lower extremities such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or, (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; or, (3) the loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or, (4) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or, (5) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbow; or, (6) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk. 38 U.S.C.A. § 2101(a); 38 C.F.R. § 3.809(b). The term "preclude locomotion" means the necessity for regular and constant use of a wheelchair, braces, crutches or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809(c). The term "loss of use" of a hand or foot is defined as that condition where no effective function remains other than that which would be equally well-served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. 38 C.F.R. § 3.350(a)(2). The determination will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or of balance, propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis. Examples which constitute loss of use of a foot, include extremely unfavorable complete ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 31/2 inches or more, or complete paralysis of the external popliteal nerve, common peroneal and consequent footdrop. 38 C.F.R. § 3.350(a)(2). Service connection has established for post-traumatic stress disorder, rated as 100 percent disabling; a right ankle disorder, rated as 10 percent disabling; peripheral neuropathy of the right foot and of the left foot, each separately rated as 10 percent disabling ; hepatitis C, rated as noncompensable; and onychomycosis and tenia pedia of the feet, rated as noncompensable. In the instant case, the evidence does not show that the Veteran has loss or loss of use of an upper or lower extremity, blindness or full thickness or subdermal burns which is related to service to a service-connected disability. Regarding the upper and lower extremities, while service connection is in effect for a right ankle disorder, as well as peripheral neuropathy of the feet and a skin disorder of the feet, there is no showing that the Veteran has loss of use of his lower extremities. It was noted on VA examination in June 2007 that the Veteran had knee problems and leg pain. He used a cane to walk. The Veteran's gait was described as slow and he walked with a wide base. He also complained of weakness in the right hand, and difficulty holding onto his cane and opening jars. Fine movements were mildly slowed in the right upper extremity, as compared to the left. Strength in the left hand was 5/5, and in the right hand, strength was 4/5. On VA examination in January 2009, it was noted that the Veteran used braces on his ankles. It was stated that he could walk without a walker 25 feet. On VA examination in December 2010, the Veteran reported wearing braces on his ankles and knees. It was noted that he had a stroke in 2003 and had been using a cane more since that time due to right side weakness. He noted numbness in his feet, especially if he stood up too long. There was decreased vibratory sense and touch in the feet. His gait was slow. Peripheral neuropathy of the feet was diagnosed and the examiner stated that the gait issues were likely related to orthopedic issues and a stroke. In short, the Veteran has no service-connected disability of the upper extremities and the clinical findings do not show loss or loss of use of a lower extremity due to the Veteran's service-connected right ankle disorder or his skin disorder. Service connection has not been established for any disability resulting in loss of visual acuity. The record also fails to demonstrate service connected blindness in both eyes, residuals of organic disease, or any other service-connected disability for which a certificate of eligibility for assistance in acquiring specially adapted housing is warranted. As the evidence does not show the requisite service-connected disabilities needed to establish entitlement to such, entitlement to a certificate of eligibility for assistance in acquiring specially adapted housing is not warranted. Increased Initial Evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 C.F.R. §38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the evaluation is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). Hepatitis C Under the Rating Schedule, a noncompensable rating is warranted with nonsymptomatic hepatitis C. 38 C.F.R. § 4.114, Diagnostic Code 7354. A 10 percent rating is warranted with intermittent fatigue, malaise, and anorexia, or incapacitating episodes, with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain, having a total duration of at least one week, but less than two weeks, during the past 12-month period. Id. A 20 percent rating is warranted hepatitis C is productive of daily fatigue, malaise, and anorexia, without weight loss or hepatomegaly, requiring dietary restriction or continuous medication, or incapacitating episodes, with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. 38 C.F.R. § 4.114, Diagnostic Code 7354. A 40 percent rating is warranted when hepatitis c caused daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or incapacitating episodes, with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain, having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. Id. In addition, for purposes of evaluating hepatitis C, an "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. Id. at Note (2). VA outpatient treatment records show that in November 2004, a hepatitis test was noted to be positive. A VA examination in January 2005, noted that the Veteran had lost 60 pounds, primarily due to hypertension and a stroke. He denied nausea, vomiting, diarrhea, abdominal pain, or fatigue. On examination, the Veteran was well-developed, well-nourished, and in no apparent distress. His abdomen was soft and nontender. The Veteran was 5 feet 7 inches tall and weighed 238 pounds. Hepatitis C was diagnosed. At a VA examination in December 2010, the Veteran reported that he had not had any symptoms of hepatitis C or any incapacitating episodes. H indicated that he was not currently being treated for hepatitis C. No abdominal abnormalities were noted on physical examination. The finding was hepatitis C, currently stable, normal liver function tests. A VA examination in September 2011 noted that the Veteran was well-nourished, with no visible stigmata of chronic liver disease. The abdomen was nontender. The examiner noted that since January 2006, all liver function tests had been normal, including the most recent test in March 2011. It was stated that there was no fatigue, malaise, anorexia, vomiting, arthralgia, or right upper quadrant pain. The examiner stated that the Veteran had gained 50 pounds over the past three to six months. The examiner diagnosed hepatitis C. Based on a review of the evidence of record, the Board finds that the Veteran's service-connected hepatitis C does not warrant a compensable disability rating under Diagnostic Code 7354. In this regard, there is no evidence that the Veteran's service-connected hepatitis C had been manifested by intermittent fatigue, malaise, and anorexia, or incapacitating episodes having a total duration of at least one week, but less than two weeks, during the past 12-month period. 38 C.F.R. § 4.114, Diagnostic Code 7354. The medical evidence shows that the Veteran's hepatitis C was in remission and it has been undetectable on laboratory testing for several years. Accordingly, the Board finds that the preponderance of the evidence is against a compensable disability rating for hepatitis C. 38 C.F.R. § 4.114, Diagnostic Code 7354. The evidence does not show that the Veteran's service-connected hepatitis C is productive of intermittent fatigue, malaise, and anorexia, or incapacitating episodes, with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain, having a total duration of at least one week, but less than two weeks, during the past 12-month period at any point during the period under appeal. Fenderson, 12 Vet. App. at 126. Throughout the period under appeal, the Veteran's hepatitis C has been considered in remission and nonsymptomatic. Id. As such, a compensable disability rating is not available under Diagnostic Code 7345. 38 C.F.R. § 4.114. The Board has considered the statements of the Veteran as to the extent of his disability. His testimony before the Board in April 2011 regarding his symptoms has been reviewed and considered. His statements are competent evidence that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture due to his service-connected hepatitis C is not so unusual or exceptional in nature as to render the already assigned rating inadequate. The Veteran's service-connected hepatitis C is evaluated as a disease of the digestive system pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7354, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Id. The Veteran's hepatitis C is not symptomatic. When comparing the disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by a noncompensable evaluation. Compensable evaluations are provided for certain manifestations of hepatitis C, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for a noncompensable evaluation reasonably describe the disability level and symptomatology of his service-connected hepatitis C. Consequently, the Board concludes that the schedular evaluation is adequate and that referral of this issue for extraschedular consideration is not required. See 38 C.F.R. § 4.114, Diagnostic Code 7354; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Bilateral Foot Onychomycosis The Veteran's service-connected bilateral foot onychomycosis is rated as dermatitis. 38 C.F.R. § 4.118, Diagnostic Code 7806. A noncompensable evaluation is warranted for dermatitis when less than five percent of the entire body or less than five percent of exposed areas are affected, and no more than topical therapy is required during the past 12-month period. A 10 percent evaluation is warranted for dermatitis that involves at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Id. A 30 percent evaluation is warranted for dermatitis that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. Throughout the period on appeal, the Veteran's service-connected bilateral foot onychomycosis did not affect at least five percent of the entire body or of exposed areas. Fenderson, 12 Vet. App. at 126. VA outpatient treatment records in May 2006, showed thick dystrophic toenails. Bilateral onychomycosis was found. A VA examination in December 2008, found no skin disorder on the feet. A VA in September 2011, found small areas of hyperpigmentation and mild scaling on the soles of the feet, bilaterally. There was maceration in the interdigital spaces of almost all toes. All the toenails had linear bands of brown discoloration. Bilaterally, the great toes and the 5th toenails had onychomycosis, dystrophy, and subungual debris. The onset and course were noted to be intermittent, and non-worsening. The Veteran was not using corticosteroid or immunosuppressive drugs. There was no functional impairment, scarring, or disfigurement. The percent of the entire body affected was less than one percent and the percent of exposed areas affected was less than one percent. The diagnoses were active tinea pedis; and active onychomycosis, affecting approximately five to seven toenails. The examiner found both disorders were mild, affecting only focal areas of the feet and several toenails. In an addendum to this examination in October 2011, the examiner indicated that systemic therapy, such as corticosteroids or other immunosuppressive drugs, was not needed for treatment. Throughout the appeal period, the record does not show that treatment for this skin disorder required systemic therapy. The disorder involved less than five percent of the entire body. Accordingly, the criteria for a compensable rating for the Veteran's service-connected bilateral foot onychomycosis are not met. 38 C.F.R. § 4.118, Diagnostic Code 7806; see also Fenderson, 12 Vet. App. at 126. In making this determination, the Board considered the lay evidence of record. As for the Veteran's statements and testimony at a hearing before the Board in April 2011 are competent evidence as to skin symptoms, as skin symptoms are capable of lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). Further, the Board has no reason to doubt the credibility of such statements as they are not inconsistent with the other evidence of record. However, the Veteran does not contend that his service-connected bilateral foot onychomycosis effected at least five percent of the entire body or of exposed areas, or that treatment for the disability has ever required systemic therapy. During the pendency of this appeal, VA revised the criteria for evaluating disabilities of the skin, effective October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). The October 2008 revisions are applicable to claims for benefits received by the VA on or after October 23, 2008. See 73 Fed. Reg. 54708 (September 23, 2008). In this case, the Veteran filed his claim in 2004, prior to that time. See VAOPGCPREC 7-03, 69 Fed. Reg. 25179 (2004). The Board finds that the Veteran's disability picture due to his service-connected bilateral foot onychomycosis is not so unusual or exceptional in nature as to render the currently assigned rating inadequate. The Veteran's service-connected bilateral foot onychomycosis is evaluated as a disease of the skin pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7806, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Id. The Veteran's bilateral foot onychomycosis effects less than five percent of the total body area, and does not require intermittent systemic therapy. When comparing the disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the manifestations of his bilateral foot onychomycosis are congruent with the disability picture represented by a noncompensable evaluation. Compensable evaluations are provided for certain manifestations of bilateral foot onychomycosis, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for a noncompensable evaluation reasonably describe the disability level and symptomatology of his service-connected bilateral foot onychomycosis. Consequently, the Board concludes that the schedular evaluation is adequate and that referral of this issue for extraschedular consideration is not required. See 38 C.F.R. § 4.118, Diagnostic Code 7354; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to a compensable evaluation for bilateral foot onychomycosis, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for malaria is denied. A certificate of eligibility for assistance in acquiring specially adapted housing is denied. An initial compensable rating for hepatitis C is denied. An initial compensable rating for bilateral foot onychomycosis is denied. REMAND Residuals of a Stroke The Veteran contends that service connection is warranted for residuals of a stroke, as secondary to his service-connected post-traumatic stress disorder. The Veteran's service treatment records show no complaint, diagnosis, or treatment for a stroke. After service, private records show that the Veteran was treated in December 1996 for an interventricular hemorrhage. VA outpatient record of June 2004 reports a history of the Veteran having a left stroke, with right hemiparesis, in November 2003. In a November 2008 letter, a private examiner reported that the Veteran had a history of post-traumatic stress disorder and that he had a stroke on November 21, 2003. The examiner reported that there seemed to be a direct connection between the Veteran's stress and anxiety, "more likely than unlikely," related to his service causing him to become stressful, nervous, and anxious with accompanying insomnia and panic attacks, contributing to his subsequent stroke. It was noted that the Veteran presently had significant speech pathology from his stroke, had difficulty forming words and verbally expressing himself. It was noted that the Veteran's condition was not expected to improve and should be considered permanent. A VA examination in December 2008, reported that the Veteran had been on treatment for post-traumatic stress disorder for approximately four years. The examiner stated that the Veteran's first stroke was in December 1996, when he presented with a severe headache but no neurological deficit and was found on computed axial tomography scan to have a left intracerebral hemorrhage. The examiner noted that the Veteran reported having a recurrent stroke in 2003, but that the records of this were not of record. The Veteran was examined and the clinician diagnosed a cerebrovascular accident, which occurred prior to the Veteran's treatment with psychotropic drugs. It was stated that in addition, the clinical evidence reflects no suspicion for drug-related neurological defects in the terms of stroke. The examiner stated that therefore, it was "less likely than not" that the Veteran's cerebrovascular accident was related to his treatment for post-traumatic stress disorder. In August 2011, the Board remanded this claim for an addendum opinion. The examiner was given specific instructions to include to consider and comment upon the November 2008 letter from a private examiner. An addendum opinion was rendered in August 2011. However, the examiner did not comment on the November 2008 letter when rendering his opinion. The Board mandated that the Veteran be evaluated under clearly specified conditions and the Board directed that specific evidence must be commented upon. The mandates presented by the Board were not adequately followed or addressed. A remand of this claim is necessary to ensure compliance with the prior Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is remanded for the following actions: 1. A supplemental opinion must be obtained from the December 2008/August 2011 VA examiner with respect to the Veteran's claim of entitlement to service connection for residuals of a stroke, to include as due to his service-connected posttraumatic stress disorder. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. All residuals of the Veteran's stroke must be reported in detail. The examiner must provide an opinion as to whether the Veteran's stroke was related to his military service or was due to or aggravated by a service-connected disability, to include the Veteran's posttraumatic stress disorder. In addressing this issue, the examiner must specifically consider and comment upon E.B.T., D.O.'s November 2008 letter. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report must be typed. If the December 2008/August 2011 VA examiner is unavailable or unable to provide the requested supplemental opinion, the Veteran must be afforded another VA examination to ascertain whether the Veteran's stroke and the residuals thereof are related to his active duty service or to a service-connected disability, to include on the basis of aggravation. When addressing the etiological relationship, if any, between the Veteran's stroke/stroke residuals and his service-connected posttraumatic stress disorder, the examiner must consider and comment upon E.B.T., D.O.'s November 2008 letter. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The examination report must be typed. 2. The RO must notify the Veteran that it is his responsibility to report for any scheduled examinations and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for a scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 3. The medical report must be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 4. After completing the above action, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, the Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs